Maldonado v. Berryhill
| Decision Date | 04 September 2019 |
| Docket Number | CIVIL ACTION NO. 18-11255-ADB |
| Parties | EDDIE ECHEVARRIA MALDONADO, Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant. |
| Court | U.S. District Court — District of Massachusetts |
REPORT AND RECOMMENDATION RE: PLAINTIFF'S MOTION TO REVERSE OR REMAND THE DECISION OF THE COMMISSIONER (DOCKET ENTRY # 16); DEFENDANT'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION (DOCKET ENTRY # 18)
Pending before this court are cross motions by the parties, plaintiff Eddie Echevarria Maldonado ("plaintiff") and defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration ("the Commissioner"). Plaintiff seeks to reverse or remand the decision of the Commissioner pursuant to 42 U.S.C. § 405(g). (Docket Entry # 16). The Commissioner moves for an order to affirm the decision. (Docket Entry # 18). On March 4, 2019, this court conducted a hearing and thereafter took both motions (Docket Entry ## 16, 18) under advisement.
In early 2013, plaintiff filed an application for disability insurance benefits. (Docket Entry # 13-8, Tr. 529- 30). Plaintiff filed an additional application for supplemental security income ("SSI") in December 2013. (Docket Entry # 13-8, Tr. 538-46). In both applications, plaintiff alleged disability rendering him unable to work as of January 25, 2013. (Docket Entry # 13-8, Tr. 529, 538). The Social Security Administration ("SSA") denied both claims on June 27, 2014. (Docket Entry # 13-7, Tr. 442-55). Plaintiff then filed a request for reconsideration, which was denied on November 18, 2014. (Docket Entry # 13-7, Tr. 461-62, 466-76).
Plaintiff requested a hearing before an Administrative Law Judge ("AJL") on December 1, 2014. (Docket Entry # 13-7, Tr. 477-78). The AJL conducted a hearing on April 29, 2016. (Docket Entry # 13-5, Tr. 294-338). Both plaintiff and a vocational expert ("VE") testified at the hearing (Docket Entry # 13-5, Tr. 294-338). In an August 26, 2016 decision, the ALJ concluded that plaintiff was not disabled under 42 U.S.C. §§ 216(i), 223(d), 1614(a)(3)(A) for the period of January 25, 2013 through the date of the ALJ's decision. (Docket Entry # 13-2, Tr. 15-32).
Plaintiff requested a review of the ALJ's decision by the Appeals Council on October 21, 2016. (Docket Entry # 13-7, Tr. 526-28). The Appeals Council denied the request for review on May 7, 2018, thereby affirming the ALJ's decision as final. (Docket Entry # 13-2, Tr. 1-4). Plaintiff subsequently filedthis action against the Commissioner pursuant to 42 U.S.C. § 405(g).
Plaintiff, born on October 30, 1967, was 45 years old on the date of his application for disability insurance benefits, and 46 years old on the date of his application for supplemental security income. (Docket # 13-8, Tr. 529, 538). He holds a high school diploma and has past relevant work experience as an auto parts salesperson and a handyman. (Docket Entry # 13-5, Tr. 306, 308-10). Plaintiff alleged an inability to work as of January 25, 2013 and claimed that he suffered from both physical and psychological conditions. (Docket Entry # 13-5, Tr. 311-23, 529) (Docket Entry # 13-8, Tr. 538).
On February 10, 2013, plaintiff was admitted to the emergency room at St. Luke's Memorial Hospital in Ponce, Puerto Rico for bilateral leg pain. (Docket Entry # 13-23, Tr. 1915-17). The attending physician, Alexandra Vega Lagares, M.D.("Dr. Vega Lagares") observed no edema in plaintiff's extremities and attributed his discomfort to uncontrolled blood glucose levels. (Docket Entry # 13-23, Tr. 1916). Dr. Vega Lagares subsequently diagnosed plaintiff with peripheral neuropathy.2 (Docket Entry # 13-23, Tr. 1916).
On April 23, 2013, plaintiff completed an adult function report.3 (Docket Entry # 13-9, Tr. 576-84). Therein, he reported that his physical ailments negatively impact his ability to care for himself, indicating that he struggles to raise and lower his legs when dressing and bathing. (Docket Entry # 13-9, Tr. 578). Plaintiff reported that he prepares his own meals, but only spends ten to 15 minutes at a time preparing food, as it is painful for him to spend more than short periods of time on his feet. (Docket Entry # 13-9, Tr. 578). Plaintiff further indicated that he is unable to independently complete tasks around the house, such as washing clothes or cleaning, and depends on his wife to do the shopping. (Docket Entry # 13-9,Tr. 579-80). Plaintiff reported that because of the strong pain in his legs, he leaves the house only when he has medical appointments. (Docket Entry # 13-9, Tr. 580). Plaintiff indicated that he remains capable of managing his own money and paying bills. (Docket Entry # 13-9, Tr. 580).
On July 3, 2013, plaintiff underwent a consultative examination with Nilma E. Rosado Villanueva, M.D. ("Dr. Rosado Villanueva"). (Docket Entry # 13-12, Tr. 858-69). At the examination, plaintiff reported a history of uncontrolled diabetes, high blood pressure, multiple heart attacks, and chest pain. (Docket Entry # 13-12, Tr. 858). Plaintiff reported being hospitalized six times between 1998 and 2013 due to chest pain, coronary artery disease, and uncontrolled diabetes, including a hospitalization for the placement of four stents in his heart. (Docket Entry # 13-12, Tr. 858-59). Plaintiff further reported experiencing frequent cramping, numbness, and spasms in his legs and shortness of breath during moderate physical activity. (Docket Entry # 13-12, Tr. 859). Dr. Rosado Villanueva noted that plaintiff used a cane for gait stability on his right side. (Docket Entry # 13-12, Tr. 858, 860). Upon physical examination, Dr. Rosado Villanueva observed "[p]alpable peripheral pulses" and lack of edema in plaintiff's legs. (Docket Entry # 13-12, Tr. 860). Plaintiff also exhibited a full range of motion and normal muscle strength in the upper andlower extremities. (Docket Entry # 13-12, Tr. 860, 865-66). Dr. Rosado Villanueva ultimately assessed diabetes, diabetic neuropathy, and left ventricular hypertrophy in addition to plaintiff's history of coronary artery disease and high blood pressure. (Docket Entry # 13-12, Tr. 861).
State agency physician Ivan Arzola, M.D. ("Dr. Arzola") completed a physical portion of a "Disability Determination Explanation" at the initial level on September 21, 2013. (Docket Entry # 13-6, Tr. 339-49). He determined that plaintiff suffers from multiple medically determinable impairments, including ischemic heart disease, which Dr. Arzola assessed as severe, as well as essential hypertension, diabetes, and peripheral neuropathy, all of which Dr. Arzola assessed as non-severe. (Docket Entry # 13-6, Tr. 347). Dr. Arzola's physical residual functional capacity ("RFC") assessment reflects that plaintiff is capable of lifting 50 pounds occasionally and 25 pounds frequently. (Docket Entry # 13-6, Tr. 347-48). Dr. Arzola also assessed that plaintiff can stand and/or walk with normal breaks for approximately six hours in an eight-hour workday. (Docket Entry # 13-6, Tr. 348). Dr. Arzola's RFC assessment further notes that plaintiff is capable of sitting with normal breaks for approximately six hours in an eight-hour workday. (Docket Entry # 13-6, Tr. 348).
On September 23, 2013, plaintiff was admitted to the emergency room at Lowell General Hospital. (Docket Entry # 13-12, Tr. 895-929). He complained of persistent bilateral leg pain and estimated that it began in January 2013. (Docket Entry # 13-12, Tr. 898). Emergency Department Nurse Tracey Correia-Mcgowan, RN prescribed plaintiff acetaminophen and tramadol for the pain. (Docket Entry # 13-12, Tr. 909-27). Plaintiff was additionally given educational materials relating to peripheral neuropathy, a diabetic diet, and the health effects of smoking. (Docket Entry # 13-12, Tr. 909-27).
On October 1, 2013, plaintiff established care with Mukund Gupta, M.D. ("Dr. Gupta") at Lowell Community Health Center. (Docket Entry # 13-14, Tr. 1088-90). As part of his medical history, plaintiff reported current tobacco use and estimated smoking between 11 and 19 cigarettes per day. (Docket Entry # 13-14, Tr. 1088). Upon a physical examination, Dr. Gupta observed no edema and noted that despite plaintiff's knees being sensitive to palpitation, plaintiff exhibited a normal range of motion in his extremities. (Docket Entry # 13-14, Tr. 1089). Dr. Gupta assessed plaintiff's diabetes as poorly controlled and referred him to diabetic management for counseling on diet. (Docket Entry # 13-14, Tr. 1089). Dr. Gupta also referred plaintiff to Scott Sigman, M.D. ("Dr. Sigman"), an orthopedist,for possible osteoarthrosis in plaintiff's knees. (Docket Entry # 13-14, Tr. 1089).
On November 13, 2013, plaintiff saw Dr. Sigman at Merrimack Valley Spine Center. (Docket Entry # 13-13, Tr. 1040-42). Dr. Sigman observed that plaintiff ambulated with a normal gait and did not walk with any assistive device. (Docket Entry # 13-13, Tr. 1041). Upon a physical examination, Dr. Sigman noted that plaintiff had a small open wound on his left calf. (Docket Entry # 13-13, Tr. 1041). Dr. Sigman further observed normal range of motion in both knees, despite tenderness when palpitated, and general atrophy in both right and left quadriceps. (Docket Entry # 13-13, Tr. 1041). Plaintiff underwent x-rays in both knees on the same day and Dr. Sigman assessed patellofemoral chondromalacia. (Docket Entry # 13-13, Tr. 1041-42). Dr. Sigman recommended "outpatient physical therapy and bilateral knee braces," and noted that he would not recommend or consider cortisone injections until plaintiff's blood sugars were under control and the wound on his left leg had healed. (Docket Entry # 13-13, Tr. 1041-42).
Beginning on November 20, 2013, plaintiff attended six sessions of outpatient physical therapy at Northeast Rehabilitation Hospital Network ("Northea...
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